Case Studies

Case 1 – Esperanca Clinic, Santarem Amazon 2004

Serafin came in for a clinic consultation with his nephew. He was a 73 year old tapioca worker who had a violent reaction to a medication. He had fever and joint swelling. Then the skin over his entire body reddened and begin to peel off. As I examined him I couldn’t believe how thick the pile of skin had already developed. For some reason, although I had never seen a case, I knew it was Steven-Johnson’s Syndrome, an autoimmune reaction triggered by his medication. Serafin was vehemently opposed to hospitalization, but I told he and his nephew that without the Intravenous steroids he would probably die. Carefully writing his diagnosis and treatment regimen in Portuguese we sent him to the General Hospital. For three days we checked the hospital but they had no record of him.

A week later Serfin walked into the clinic smiling. He had never been formally admitted. However, he had laid on a gurney, in the hall, and received his IVs for 72 hours. Now he was getting well. He told me he would like to see me as a doctor, but I was too expensive. Our clinic charges eighty cents if a patient can afford to pay, or nothing if not. I told him he was well and no longer needed my services. And besides, I had saved him a lot of money. He peered at me inquiringly ….Funeral expenses I said. We laughed and hugged and said goodbye

Initial Diagnosis

Returning to his family

Case 2 – Hospital Boat, Moura Village Quilombo – 2002

We had had a busy day at Moura. Leaving Santarem at 8am Thursday. It was a 21 hour boat ride to our mooring in the middle of the Trombetos River. The mourning and the afternoon sessions had gone smoothly. As we were finishing, a mother brought in her 12 year old son, Marco – pale, shivering and lethargic. It was clear he was very dehydrated, but of more concern was the paleness of his anemia. Then he began to shake with chills followed by 104 degree temperature. Our make-shift lab had already identified the two types of malaria he had. One was Plasmodium Falciparum, the most deadly of the four types. The real problem was not just his extremely low hemoglobin of 5, but that this was his third attack in 21 days and he had been treated with the right regimens previously. That meant that the malaria had become resistant to his regimen and had destroyed his red blood cells exploding them to hemoglobin of 5.

I needed to find the appropriate regimen for his resistant strain. It was a puzzle. What had he been taking? What did we have on the boat? His new regime of 8 medications, including all 5 of my mefloquin, took me nearly 2 hours to calculate, milligrams per kilograms. We started him off with the right combination and sequence. Carefully we reiterated the new regimen to his mother before leaving on the river. Exhausted, we had showers, diner and collapsed in our hammocks in the darkness as the boat motored to tomorrows village, Tapagem to be followed by our trip back to Satarem. I thought about Marco during the year. He came to see me the next year, smiling he said hello. He had made it and looked splendid.

Chills with High Fever

Profound Anemia

Enlarged Spleen

Slide of Malaria Parasite

Case 3 – Alligator Bite, Santarem Amazonia 1992

I had just arrived in Santarem attending my first medical clinic. The father carried the twelve year old into the treatment clinic. On unwrapping the cloth from his leg, I knew we had our work cut out for us. Renaldo had been net fishing from in the water’s edge with his brother. A sharp stab gripped his calf and drew him away from shore. The grip was loose, however, and when the jacari (an Amazon crocodile) loosened to get a firmer hold, Renaldo scampered out of the river. Skin, muscle, subcutaneous tissue were scrapped from below his knee to his ankle. Today was after a five day boat trip down the Amazon to our clinic Esperanca.

A volunteer Orthopedic Team from three weeks earlier had left me the IV antibiotics I would need for the infection that the jungle always brings from such bites. He would arrive at 4am for an oral opiate for anesthesia and we would start the painful and tedious process of debridement. After ten days his leg began to pinken. I would have to leave before he was done, but the nurses had the debridement regimen down. He recovered completely requiring no skin graft and with a perfect gait. Moral of story: “Wrong place, wrong time turned to right place, right time and a great outcome”